<form id="form" action="<?=$_SERVER[ 'PHP_SELF' ]?>" method="post">
	<div class="form">
		<div class="fields">
			<div class="label">
				<label id="title">Bank</label>
			</div><br/><br/>
			<div class="field">
				<div class="label">
					<label for="name_owner">Bank Name:</label>
				</div>
				<div class="input">
					<input type="text" name="bank_name" value="<?=$bank_name?>" class="small" />
				</div>
			</div>
			<div class="field">
				<div class="label">
					<label for="birth_owner">Bank Branch:</label>
				</div>
				<div class="input">
					<input type="text"  name="bank_branch" value="<?=$bank_branch?>" class="small" />
				</div>
			</div>
			<div class="field">
				<div class="label">
					<label for="email">Bank Account Name:</label>
				</div>
				<div class="input">
					<input type="text" name="bank_account_name" value="<?=$bank_account_name?>" class="small" />
				</div>
			</div>	
			<div class="field">
				<div class="label">
					<label for="phone">Bank Account Number:</label>
				</div>
				<div class="input">
					<input type="text" name="bank_account_number" value="<?=$bank_account_number?>" class="small" />
				</div>
			</div>
			<div class="field">
				<div class="label">
					<label for="building">Remark:</label>
				</div>
				<div class="textarea">
					<textarea style="resize: none;" rows="3" name="agent_address" cols="40"></textarea>
				</div>
			</div>
			<div class="field">
				<div style="margin: 0 10px 0 35px" class="button">
					<input type="submit" value="Submit" />
				</div>
				
				<div class="button">
					<input type="reset" value="Reset" />
				</div>
			</div>			
		</div>
	</div>
</form>